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Student Name Course title Course code Institution of Affiliation Assessor’s name Date of submission Compartment Syndrome It refers to the increased pressure in the interstitial tissue with the confined space in our bodies which leads to poor tissue perfusion and it eventually leads to necrosis of the tissues within that compartment. Compartment syndrome is an a true orthopedic Emergency Past Events The use of explosives in terrorism attacks has led to mass casualty incidents worldwide. The injuries that result from explosives causes compartment syndrome. The recent examples of massive incidents include: Tel Aviv (2001), Madrid Subway (2005), Mumbai (2006) and London subway (2004). The number of compartment syndrome was rampant in almost all the survivors. They sustained serious injuries which turned out to be compartment syndrome. Pathophysiology of compartment syndrome The classical pathogenesis is as follows: there is increased ICP in interstitial tissues over the perfusion pressure of capillaries. The accumulation of the necrotic tissues raises ICP within the closed compartment. The pressure goes to a high level impairing circulation of within the compartment. Then contents undergo necrosis of varied degrees of necrosis and fibrosis eventually. The normal intramuscular resting pressure is normally less than 6mmHg. Resting intramuscular pressure increases to more than 100mmHg in compartment syndrome. Initially the insult causes either hemorrhage and edema or both of them in closed fasciae compartments of extremities. Continued increase in pressure will eventually lead to tamponade of the compartment, microcirculatory and sustained ischemia. Triage and identification After an accident, the triage is done to save life. There are those that need resuscitation, emergent case, urgent and not urgent. The procedure is to identify compartment syndrome various depending on the severity and nature of the injuries. Resuscitation is the first step in the field before transportation to the hospital. You cannot transport victims who are not stable to the hospital. The primary ai9m of triage is to stabilize the victims to ensure respiratory and circulation system is fine. The process of triage can be overpowered by increased number of the victims. A large number of patients will slow down triage. Increased number of patients will delay the process of transporting them to hospitals for further management. The response team is likely to be overwhelmed by large number of the patients. Signs and symptoms Compartment syndrome is associated with the 6"Ps“. 1. Pain 2. Pallor 3. Paraesthesia 4. Pulseless 5. Paralysis 6. Poikilothermic The three first signs of compartment syndrome include: numbness, tingling and paraesthesia. Complications in delayed treatment 1. Volkmann’s contracture 2. Amputation 3. Weak dorsiflexors 4. Sensory loss 5. Claw toes 6. Rhabdomyolysis 7. Chronic pain 8. Renal failure Causes of compartment syndrome There are many causes of compartment syndrome. 1. Increased compartment volume: Fracture, soft tissue injury, iatrogenic and exertion. 2. Decreased compartment volume: Tight splints, lengthy surgeries, comatose patient, prolonged limb pressure and excessive traction. Blast injuries It is another common cause of compartment syndrome. They are divided into four categories: 1. Primary which is caused by wave of blast. 2. Secondary injury is caused by flying debris. 3. Tertiary injury is caused by blast wind. 4. And lastly, quaternary is caused by heat and radiation. Pre-hospital management The treatment starts at the scene of the accident or blast. Triage is an important part to stabilize patients. The goal of managing acute compartment syndrome is restoration of tissue perfusion. The purpose of pre-hospital management is to stop any respiratory problems and stop any possible blood loss due to the injury. Stabilize the patient by ensuring patency of the airway system so that the patient arrives in hospital in normotensive state. Non- operative management The patient must be normotensive to prevent further injury of tissues. The casts and circumferential bandages are removed. Immobilization and fixation should continue in order to maintain fracture reduction. Raise the limb to the level of the heart. It will reduce arterial inflow on which perfusion depends. Administer supplemental oxygen. An indwelling catheter will be used to monitor borderline symptomatic patients. Doubtful patients should have fasciotomy compared to delay treatment. Fasciotomy is the prophylactic release of pressure from the compartment before permanent damage takes place. Operation Management The gold standard is fasciotomy. INDICATIONS 1. There must unequivocal and proper clinical findings to warrant fasciotomy 2. The pressure of the closed compartment of about 15-20 mmHg. 3. Continued tissue pressure increase in the compartment. 4. High risk patient, greater than 6 hours of the total limb ischemia 5. Injury which is known for its high risk, for example the blast injuries. 6. Absolute: >30-35mmHg supported by clinical correlation CONTRA-INDICATIONS In case of missed compartment syndrome, it should be within (>24-48 hrs.) Principles of Fasciotomy a. Diagnosis should be made early b. Long extensile incision c. Release total fasciae compartments d. Preserve all neurovascular structures e. Debride all necrotic tissues f. Coverage within 7 to 10 days References 1. McQueen, M. M., & Gaston, P. (2000). Acute compartment syndrome. Bone & Joint Journal, 82(2), 200-203. 2. Burch, J. M., Moore, E. E., Moore, F. A., & Franciose, R. (1996). The abdominal compartment syndrome. Surgical Clinics of North America, 76(4), 833-842. 3. Sheridan, G. W., & Matsen, F. A. (1976). Fasciotomy refers to treatment of acute compartment syndrome. The Journal of Bone & Joint Surgery, 58(1), 112-115. 4. Fietsam Jr, R., Villalba, M., Glover, J. L., & Clark, K. (1989). Intra-abdominal compartment syndrome as a complication of ruptured abdominal aortic aneurysm repair. The american surgeon, 55(6), 396-402.